3. Adding an Insurance Plan
In the "Quickstart" section of this chapter, you learned how to clone an existing insurance company and make minor changes. This section will revisit this process and explain all the additional features and fields used when adding an insurance company.
Run the table editor (ted). If you have never run ted before, you should ask your system administrator or contact PCC for assistance (800-722-1082, support@pcc.com).
Choose table #3, "Insurance Companies."
The Insurance Company table will appear. This screen gives you a quick summary of carrier information.
You can either type A to add a new plan from scratch or type C to clone an existing insurance plan as discussed in the section above. Even if you plan to make major changes, PCC recommends you use the "Clone" feature. This will ensure that every required field is filled out.
Whether you are adding a plan or cloning a plan, you will see a screen with details about your new insurance plan. Fill in the each field as described here and press Enter to move from field to field.
These boxes need to be filled in with the following information:
Fields in an Insurance Plan Information Screen
- Insurance Group
Individual plans are grouped together for Practice Management Reports. You can use the asterisk (*) in this field and include this plan in an already existing insurance group. (See the information on ted to learn how to add new insurance groups).
- Plan Name
The name of the insurance plan. Always include the default copay amount in the plan name so it can be easily differentiated. Some offices also include the PO Box used for claim submission to ensure the correct plan is always selected.
- Short Name
An abbreviated name for the insurance plan. It is used when displaying the plan name in various place in Partner.
- Address
The mailing address that will appear on paper claims.
- HCFA Batch
The batch that controls claim grouping and formatting for this plan. Individual plans are grouped in these batches for the purpose of generating similar claims. You can use the asterisk (*) to see a list of existing HCFA batches. Plans with the same HCFA batch generally share provider ID#s and other options controlled in the Configuration Editor (ced). The HCFA batch that claims are grouped into has no connection to the Insurance Group field.
If you believe you need to add a new batch for some reason, contact PCC and a Customer Care technician will assist you.
- Group Claims By:
This field was originally used for controlling active plans. It is no longer needed and can be ignored.
- Eligibility ID, Ins Type, Filing ID, Subs Filing ID, Aux Payor ID
These fields are used in special circumstances for claim submission. They were added due to HIPAA changes to claim submission formats. You can ignore these fields unless directed by PCC. Do not change the text in these fields.
- Payor ID
The identification number used for electronic claim submissions to this plan. Insurance plans from the same company generally share the same Payor ID number.
- Special Information File
The path to the ibar file. Insurance plans use these files as a filter for all procedures. The file defines whether or not each procedure should pend, HCFA, or capitate. It can also define special copay situations. See the ibar section below for more information. You can use the asterisk (*) to see a list of ibar files on your system. If you have cloned an insurance company, then this field is probably filled out appropriately already.
- Is this a Medicaid plan?
A Yes/No question that determines whether this plan will behave like a medicaid plan. If set to "Yes," charges will not pend this insurance unless the patient involved has the "Medicaid" status flag on their Status field in the patient editor (notjane).
- Is this a capitated plan?
A Yes/No question that sets the default capitation behavior for this plan. If set to "Yes," charges posted to this plan will be adjusted off at the time of service. Keep in mind that the Special Information File will overrule this question.
- Default copayment
The expected copay amount for this plan. You should enter this information in the name of the plan as well as here, so that selecting the plan will be easy for your staff. Keep in mind that the Special Information File can overrule how much copay to charge for each procedure.
If your new plan has different copay amounts for different types of procedures, put the most common or default copay in this box. The Special Information File can be configured to automatically set the copay for each procedure. Read the ibar section below for more information.
- Accept Assignment
A Yes/No question that turns pending for this plan on and off. If this plan does not accept assignment, then charges posted to it will remain the personal responsibility of the guarantor and will not generate claims. Keep in mind that the Special Information File may override this setting and force charges to pend to the insurance company.
- Copay Questions
A series of Yes/No questions that determine copay behavior for this insurance plan. If there is no copay then you don't need to bother with these questions. Otherwise, use them to define how and when the copay is expected. The first should almost always be set to yes, as it assigns a copay for a visit to the doctor's office. The second question defines whether a copay should be charged for hospital visits. The final question sets one copay for every procedure. Keep in mind that the Special Information File can also control and affect what copay is charged and for which procedures.
If you want to enter any specific notes relating to this plan you can press [F8 -- Change Notes]. The notes you add will be visible to the person posting charges for any account with this insurance plan.
After completing the insurance screen and any notes, you must save your work by pressing [F1 -- Save and Quit]. This will bring you back to the Insurance Company table, and your newly added plan will be properly inserted in the alphabetical list of all your plans.
You have now successfully added an insurance plan to your system and are ready to start using it.